Promoting reflection on bioethics and research ethics issues in Sub-Saharan Africa

Wednesday, March 01, 2006

Male Circumcision: all the rage in Swaziland

Mbabane Clinic in Swaziland has recently seen a sharp rise in the number of men seeking to be circumcised. Or perhaps that is putting it too lightly: the administrator of the clinic, Dr. Mark Mills, described it as a ‘stampede’ that nearly culminated in a ‘circumcision riot.’ Mbabane clinic has, in fact, hired two new doctors full-time just to meet the rising demand, and all this despite circumcision being traditionally foreign to Swaziland.

The new-found desire for male circumcision clearly stems from a recent, randomized controlled study in South Africa indicating that male circumcision may reduce risk of HIV acquisition. Those results have been supplemented by new data presented in Denver last month that suggests circumcision may also protect transmission of HIV from men to women. In an increasingly interconnected world, word soon trickles down from international conferences to African towns and villages.

In a country where roughly 40 percent of the adult population is believed to be HIV positive, the idea that a relatively cheap surgical procedure could provide some protection against HIV is a very attractive prospect. For its part, the Swaziland Ministry of Health is not really heeding WHO/UNAIDS recommendations to exercise caution and wait until the results of other circumcision studies in Uganda and Kenya are made available. The Ministry is already promoting the practice as an HIV prevention tool, and has funded a circumcision refresher course for local doctors.

In the background of all this is a raging debate on research that has tried to establish an association between HIV transmission and male circumcision for the last twenty years. Critics of the research point out that HIV has taken the greatest toll on the African continent, where roughly two-thirds of the men are already circumcised, and argue further that behavioral, cultural and economic (rather than anatomical and biological) factors are the main forces driving the transmission of HIV in Africa and elsewhere.

The stakes are very high. If the recent research findings are correct, male circumcision is -- given the failure to discover an effective vaccine -- a much needed tool in the struggle against HIV/AIDS. If critics of the research are correct, then the well-publicized promotion of male circumcision is a dangerous distraction, and men (and women) in Swaziland are being given false hope.